Provider Demographics
NPI:1386955748
Name:DEBACCO, LAURA MARJORIE (PA-C)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:MARJORIE
Last Name:DEBACCO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:MARJORIE
Other - Last Name:MALYSZA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RPA-C
Mailing Address - Street 1:5927 MILITARY RD
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:NY
Mailing Address - Zip Code:14092-2218
Mailing Address - Country:US
Mailing Address - Phone:716-297-9379
Mailing Address - Fax:716-297-4638
Practice Address - Street 1:5927 MILITARY RD
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:NY
Practice Address - Zip Code:14092-2218
Practice Address - Country:US
Practice Address - Phone:716-297-9379
Practice Address - Fax:716-297-4638
Is Sole Proprietor?:No
Enumeration Date:2010-06-30
Last Update Date:2022-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014039363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03326510Medicaid